Mephentermine abuse – A case report

Sir,

Mephentermine sulfate, which is structurally similar to methamphetamine, acts directly and indirectly on the noradrenergic receptors,[1] leading to high levels of norepinephrine release owing to its sympathomimetic action, enhancing aggressive behaviors via the noradrenergic projections from locus coeruleus, the principal norepinephrine synthesis site which is involved in the regulation of levels of arousal, flight and fight responses, agitation, sleep–wake cycle as well as aggressive behaviors. Surveying literature on mephentermine abuse or dependence yielded limited case reports on the same.[2,3,4] We report here a case of mephentermine abuse.

A 25-year-old male, bank employee by profession, working as a part-time gymnasium instructor, residing in Mumbai, was brought to our outpatient department by his father. He complained of irritability, aggression, and insomnia with ongoing abuse of injectable mephentermine sulfate over the last 2 years. The father mentioned that the patient was introduced to mephentermine by friends 2 years ago who advised him to take it to improve his stamina and physique. The patient took 30 mg of mephentermine intramuscularly following which he felt energetic and was able to exercise better. The patient gradually increased the dose to 900 mg/day.

The father noticed marked change in his behavior. He would barely sleep for 3–4 h at night, get increasingly irritable, and engage in altercations with family and friends on trivial issues, later repenting. In one instance following a prank played by one of his friends, the patient got so enraged that he broke into his house and assaulted him till four adult men forcibly restrained him. Unable to control him, the police were called who took him to a mental health facility where he was admitted; details of treatment were not available, however. He remained abstinent for the next 6–7 months, with marked improvement in his behavior. He restarted mephentermine without the knowledge of his family members, gradually increasing the dose to 900 mg/day.

On further interview, the patient and father denied any other substance use or psychiatric illness. His premorbid personality was quick tempered, emotionally labile, extrovert, and impulsive. He was the eldest of three siblings and had no family history of mental illness.

On general examination, he was well built, weighing 70 kg with multiple puncture marks, and skin discoloration over both his deltoid and gluteal region. His vital parameters were normal. He denied any delusions, death wishes, or suicidal ideations but expressed a craving for the injectable; he denied perceptual abnormality in any sensory modality. His insight was grade 2 and in the precontemplation stage of motivation cycle.

A diagnosis of stimulant use disorder (mephentermine use disorder) and traits of borderline personality as per the Diagnostic and Statistical Manual 5[5] was made. The patient was started on oral olanzapine + fluoxetine (5 + 20 mg) combination twice a day and oxcarbazepine 300 mg at night. For his withdrawal, baclofen 30 mg and naltrexone 50 mg were added once a day. The patient followed up a fortnight later with significant decrease in his irritability and aggression with improved sleep. The patient confessed to having decreased his mephentermine use to 60 mg/day. The patient was counseled to stop the same and asked to follow-up after 15 days. The patient followed up and claimed to have stopped abusing the drug. The patient is doing well and currently maintained on the above medication.

Although there is dearth of literature on mephentermine dependence, Angrist et al. published three cases of acute paranoid psychosis with hallucinations in mephentermine abusers,[6] not seen in our case. Similar case reports by Singh et al.[7] and Somani[8] described intravenous high-dose mephentermine use in young athletes with no psychotic symptoms or behavioral abnormalities, however.

There is a lack of awareness of mephentermine's potential for abuse and efforts need to be made to disseminate information regarding the same and its effective management and the need to regulate its availability.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.